TWilliam2019
Guru
Postoperative diagnosis:
#1 severe, symptomatic aortic stenosis with bicuspid aortic valve
#2 atrial fibrillation with rapid ventricular response
#3 moderate left ventricular dysfunction
#4 New York Heart Association class II symptoms
#5 newly diagnosed diabetes mellitus
#6 obesity
#7 tobacco abuse
#8 syncope
#9 moderate pulmonary hypertension
*
Procedure:
#1 urgent aortic valve replacement with 21 mm On-X mechanical valve
#2 endarterectomy of the left ventricular outflow tract and posterior aspect of the anterior mitral valve leaflet
#3 bilateral pulmonary vein isolation
#4 exclusion of left atrial appendage with a 35 mm clip
#5 cardiopulmonary bypass
#6 TEE with visualization and interpretation ×1
#7 rigid internal fixation of the sternum secondary to diabetes and obesity
33405
33259
33414
93656
76998 26 59
93314 26
Intraoperative findings:
Pre-bypass TEE was performed and interpreted by Dr. K. Please see his dictation for those results. Upon opening the aorta, the aortic valve was a bicuspid valve with a common raphe between the left and right coronary cusp. There was heavy calcific burden on the aortic valve leaflets. After decalcifying the aortic annulus, a large calcium shelf extended into the left ventricular outflow tract down the posterior aspect of the anterior mitral leaflet to its free edge. This was completely decalcified. A 21 mm on a mechanical valve was placed.
*
Post-bypass TEE was performed and interpreted by myself. The left ventricle was adequately de-aired. The left ventricular function was unchanged, with an ejection fraction of 45%. There were no regional wall motion abnormalities. The aortic prosthetic valve was well seated in the supra-annular position. There were no paravalvular leaks. The mean gradient was 14 mmHg. The mitral valve had trace to mild mitral insufficiency and was unchanged from preoperatively. Left atrial appendage was confirmed excluded.
*
Epi-aortic ultrasound revealed no evidence of disease of Dr. cannulation or cross clamp strategies. There was no aneurysm. Image was saved for permanent records.
*
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite and placed on the operating table where he underwent general anesthesia with endotracheal intubation. Monitoring lines were placed by anesthesia. TEE probe was placed by anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the surgery to be performed. Antibiotics given prior the incisions.
*
Pre-bypass TEE was performed as described above and interpreted by Dr. K. Once this was completed, midline sternal incision was made. Dissection is taken down to the soft tissues with cautery. Midline sternotomy was performed in the standard fashion. Sternal retractor was placed. The anterior mediastinal soft tissues were divided. The pericardium was opened and teed off along the diaphragm. Stay sutures placed create a pericardial well. Epi-aortic ultrasound was then used to evaluate the ascending aorta from just beyond the sinotubular junction to the level of the innominate takeoff. Findings were as described. The patient was heparinized and ACT was found be therapeutic for cannulation and bypass. Next
*
Central cannulation was then performed. Reverse autologous priming of the pump was performed. The patient was then placed on full cardiopulmonary bypass and systemically cooled to 32°C. The oblique sinus was then opened. The epicardial fat in the AV groove was then divided with electrocautery. Great care was taken to preserve the phrenic nerve throughout pulmonary vein isolation. The Wolfe dissector was then used to dissect out the right-sided pulmonary veins. The bipolar clamp was then placed and a total of 3 separate isolation lines were made. Transmurality was seen on each separate isolation line. Once this was completed, the right pleural cavity was opened.
*
Antegrade needle was then placed in the mid ascending aorta. A retrograde cardioplegia cannula was placed through the free wall the right atrium and positioned in the coronary sinus. The cross-clamp was placed and cold sinus and antegrade cardioplegia as well as retrograde cardioplegia was delivered to achieve full diastolic cardiac arrest. Temperature probe was placed in the septum. Ice was placed over the right ventricle. Goal temperature was 15°C or less throughout the procedure.
*
The heart was retracted to expose the left-sided pulmonary veins. As with the right-sided pulmonary veins, they were carefully isolated using the Wolfe dissector. The bipolar clamp was placed on the atrial cuff of the left-sided pulmonary veins. A total of 4 separate isolation lines were then created with transmural allergy being seen with each separate line. At the completion of the port a vein isolation bilaterally, the left atrial appendage was identified. It was a relatively small appendage. A 35 mm clip was placed over the appendage and positioned at the base for successful exclusion. The heart was then dropped back into the pericardial well. Next
*
The patient did receive cardioplegia roughly every 20 minutes throughout the procedure. An oblique aortotomy was then created with Metzenbaum scissors and extended towards the noncoronary sinus. The aortic valve leaflets were then excised using Metzenbaum scissors. Once this was completed, the aortic annulus was carefully decalcified. After decalcification of the annulus, the left ventricular outflow tract and mitral valve leaflets were inspected and found to have a large calcific shelf extending to the posterior free edge of the anterior mitral leaflet. This area was also completely decalcified for completion of the endarterectomy and improved leaflet mobility. The Ellik evacuator was then used to remove any microcalcific debris. 2-0 pledgeted Ethibond sutures were then placed in the sub-annular position circumferentially around the annulus. The annulus was sized to a 21 mm On-X valve, and reference shows no patient prosthesis mismatch with that size. The sutures then placed through the sewing cuff of the valve and the valve was seated in the supra-annular position. This is a difficult portion of the procedure, as the patient had a relatively narrow sinotubular junction. It was then secured using the core not device. The patient was systemically rewarmed. The aortotomy was then closed in a 2 layer fashion using 4-0 Prolene. The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After adequate de-airing, the needle vent was placed on high suction and the cross-clamp was removed. X
*
The heart was defibrillated to establish rhythm. Pacing wires were placed on the right ventricle brought out to the level of the skin. The pericardium was closed along the inferior right portion of the diaphragm. Lungs were ventilated. The heart was then weaned from cardiopulmonary bypass without difficulty. All suture lines were found to be hemostatic. Final TEE was performed and interpreted by myself with findings as described. Once this was completed, protamine was delivered to reverse the effects of heparin. The heart was decannulated with all cannulation sites oversewn with 4-0 Prolene. A 32 French right angle chest tube was placed in the right pleural cavity and a 32 French straight chest tube was placed in the mediastinum.
*
The sternum was reapproximated with #7 wires. At the midsternal body, a single cable pioneer X plate was placed. The cable was tightened and crimped into place. The plate was then seated to the sternum using 8, 14 mm screws. This. Abdominal fascia 3 proximal meter 0 Ethibond. Soft tissues reapproximated with 0 Vicryl. Skin was closed with 4 Monocryl running septic or manner. Dermabond was placed over the wound. The patient tolerated procedure well was transferred to CVRU in guarded condition.
*
Specimens: Aortic valve leaflets
estimated blood loss: 75 mL's
blood replaced: None
drains: Chest tubes as described
condition at completion of procedure: Guarded
#1 severe, symptomatic aortic stenosis with bicuspid aortic valve
#2 atrial fibrillation with rapid ventricular response
#3 moderate left ventricular dysfunction
#4 New York Heart Association class II symptoms
#5 newly diagnosed diabetes mellitus
#6 obesity
#7 tobacco abuse
#8 syncope
#9 moderate pulmonary hypertension
*
Procedure:
#1 urgent aortic valve replacement with 21 mm On-X mechanical valve
#2 endarterectomy of the left ventricular outflow tract and posterior aspect of the anterior mitral valve leaflet
#3 bilateral pulmonary vein isolation
#4 exclusion of left atrial appendage with a 35 mm clip
#5 cardiopulmonary bypass
#6 TEE with visualization and interpretation ×1
#7 rigid internal fixation of the sternum secondary to diabetes and obesity
33405
33259
33414
93656
76998 26 59
93314 26
Intraoperative findings:
Pre-bypass TEE was performed and interpreted by Dr. K. Please see his dictation for those results. Upon opening the aorta, the aortic valve was a bicuspid valve with a common raphe between the left and right coronary cusp. There was heavy calcific burden on the aortic valve leaflets. After decalcifying the aortic annulus, a large calcium shelf extended into the left ventricular outflow tract down the posterior aspect of the anterior mitral leaflet to its free edge. This was completely decalcified. A 21 mm on a mechanical valve was placed.
*
Post-bypass TEE was performed and interpreted by myself. The left ventricle was adequately de-aired. The left ventricular function was unchanged, with an ejection fraction of 45%. There were no regional wall motion abnormalities. The aortic prosthetic valve was well seated in the supra-annular position. There were no paravalvular leaks. The mean gradient was 14 mmHg. The mitral valve had trace to mild mitral insufficiency and was unchanged from preoperatively. Left atrial appendage was confirmed excluded.
*
Epi-aortic ultrasound revealed no evidence of disease of Dr. cannulation or cross clamp strategies. There was no aneurysm. Image was saved for permanent records.
*
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite and placed on the operating table where he underwent general anesthesia with endotracheal intubation. Monitoring lines were placed by anesthesia. TEE probe was placed by anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the surgery to be performed. Antibiotics given prior the incisions.
*
Pre-bypass TEE was performed as described above and interpreted by Dr. K. Once this was completed, midline sternal incision was made. Dissection is taken down to the soft tissues with cautery. Midline sternotomy was performed in the standard fashion. Sternal retractor was placed. The anterior mediastinal soft tissues were divided. The pericardium was opened and teed off along the diaphragm. Stay sutures placed create a pericardial well. Epi-aortic ultrasound was then used to evaluate the ascending aorta from just beyond the sinotubular junction to the level of the innominate takeoff. Findings were as described. The patient was heparinized and ACT was found be therapeutic for cannulation and bypass. Next
*
Central cannulation was then performed. Reverse autologous priming of the pump was performed. The patient was then placed on full cardiopulmonary bypass and systemically cooled to 32°C. The oblique sinus was then opened. The epicardial fat in the AV groove was then divided with electrocautery. Great care was taken to preserve the phrenic nerve throughout pulmonary vein isolation. The Wolfe dissector was then used to dissect out the right-sided pulmonary veins. The bipolar clamp was then placed and a total of 3 separate isolation lines were made. Transmurality was seen on each separate isolation line. Once this was completed, the right pleural cavity was opened.
*
Antegrade needle was then placed in the mid ascending aorta. A retrograde cardioplegia cannula was placed through the free wall the right atrium and positioned in the coronary sinus. The cross-clamp was placed and cold sinus and antegrade cardioplegia as well as retrograde cardioplegia was delivered to achieve full diastolic cardiac arrest. Temperature probe was placed in the septum. Ice was placed over the right ventricle. Goal temperature was 15°C or less throughout the procedure.
*
The heart was retracted to expose the left-sided pulmonary veins. As with the right-sided pulmonary veins, they were carefully isolated using the Wolfe dissector. The bipolar clamp was placed on the atrial cuff of the left-sided pulmonary veins. A total of 4 separate isolation lines were then created with transmural allergy being seen with each separate line. At the completion of the port a vein isolation bilaterally, the left atrial appendage was identified. It was a relatively small appendage. A 35 mm clip was placed over the appendage and positioned at the base for successful exclusion. The heart was then dropped back into the pericardial well. Next
*
The patient did receive cardioplegia roughly every 20 minutes throughout the procedure. An oblique aortotomy was then created with Metzenbaum scissors and extended towards the noncoronary sinus. The aortic valve leaflets were then excised using Metzenbaum scissors. Once this was completed, the aortic annulus was carefully decalcified. After decalcification of the annulus, the left ventricular outflow tract and mitral valve leaflets were inspected and found to have a large calcific shelf extending to the posterior free edge of the anterior mitral leaflet. This area was also completely decalcified for completion of the endarterectomy and improved leaflet mobility. The Ellik evacuator was then used to remove any microcalcific debris. 2-0 pledgeted Ethibond sutures were then placed in the sub-annular position circumferentially around the annulus. The annulus was sized to a 21 mm On-X valve, and reference shows no patient prosthesis mismatch with that size. The sutures then placed through the sewing cuff of the valve and the valve was seated in the supra-annular position. This is a difficult portion of the procedure, as the patient had a relatively narrow sinotubular junction. It was then secured using the core not device. The patient was systemically rewarmed. The aortotomy was then closed in a 2 layer fashion using 4-0 Prolene. The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After adequate de-airing, the needle vent was placed on high suction and the cross-clamp was removed. X
*
The heart was defibrillated to establish rhythm. Pacing wires were placed on the right ventricle brought out to the level of the skin. The pericardium was closed along the inferior right portion of the diaphragm. Lungs were ventilated. The heart was then weaned from cardiopulmonary bypass without difficulty. All suture lines were found to be hemostatic. Final TEE was performed and interpreted by myself with findings as described. Once this was completed, protamine was delivered to reverse the effects of heparin. The heart was decannulated with all cannulation sites oversewn with 4-0 Prolene. A 32 French right angle chest tube was placed in the right pleural cavity and a 32 French straight chest tube was placed in the mediastinum.
*
The sternum was reapproximated with #7 wires. At the midsternal body, a single cable pioneer X plate was placed. The cable was tightened and crimped into place. The plate was then seated to the sternum using 8, 14 mm screws. This. Abdominal fascia 3 proximal meter 0 Ethibond. Soft tissues reapproximated with 0 Vicryl. Skin was closed with 4 Monocryl running septic or manner. Dermabond was placed over the wound. The patient tolerated procedure well was transferred to CVRU in guarded condition.
*
Specimens: Aortic valve leaflets
estimated blood loss: 75 mL's
blood replaced: None
drains: Chest tubes as described
condition at completion of procedure: Guarded
